LAAC- Armchair Training

1. LAAC- Armchair Training Medi-Cal Program Basics March 13, 2008 Doreena Wong, Staff Attorney National Health Law Program 2639 S. La Cienega Blvd. Los Angeles, CA 90034 (O)(310) 204-6010, ext. 107 (F)(310) 204-0891 E-mail: wong@healthlaw.org Website: www.healthlaw.org

2. Medi-Cal Overview Eligibility: “The Worthy Poor” Requirements for Eligibility Personal Characteristics Financial Condition Proper Immig. Status or Proof of Citizenship State Resident Low Income Limited Resources Category of Worthy

3. Medi-Cal Overview Mandatory & Optional Eligibility Categories Eligibility Categories Mandatory Groups Optional Groups Eligible for, but not applied for SSI or CalWORKs Families, Children, Pregnant Women Pregnant women, Infants up to 185% FPL Persons who are Aged, Blind, or Disabled Medically Needy 65 or older or disabled up to 100% FPL Persons losing TANF/CalWORKs

4. Proof of Citizenship or Immigration Status • Deficit Reduction Act of 2005 (DRA) changed how citizens must prove their citizenship in Medicaid (Medi-Cal in California) • Prior to the DRA, citizens signed an affidavit declaring their citizenship • U.S. Citizens and nationals will have to submit proof of citizenship • Satisfactory Immigration Status

5. What about immigrants? • The DRA did NOT change any requirements for immigrants to show proof of their immigration statuses. • Immigrants do not need to show any new documents. • Immigrants need only show documentation of their immigration status (as before) in order to get Medi-Cal coverage other than restricted scope coverage • Immigrants can continue to get the same types of Medi-Cal as before.

6. Who does the law affect? • Many U.S. citizens and… • People born in the U.S., including people born in Puerto Rico, U.S. Virgin Islands, Guam • People who were naturalized as U.S. citizens • U.S. Nationals… • People who were born in American Samoa including Swains Island • Who are applying for or continuing to receive Medi-Cal as citizens

7. Residency • Certain state and local benefit programs require California or county residency for eligibility • Different from immigration status • Resident if : physically present and living in the state/county with the intent to remain permanently or for an indefinite time • Required to sign a declaration and provide supporting documents

8. Children’s Residency • Normally based on parents’ residency • Parents who do not have residency can establish residency for their children if the parents: • Intend for the children to remain in the state/county on other than a temporary basis, and; • Have made arrangements for the children to remain independent of the parent

9. Medi-Cal OverviewFinancial Eligibility General rule: Look to the cash assistance category (i.e. SSI or CalWORKs) that the beneficiary is most closely linked to. • Income • Earned • Unearned • Exempt income • Resources or assets • Individual: $2000, Couple: $3000 • Exempt resources (e.g. home) • Availability of income or resources • Deeming - Whose income/property is counted? Who has a financial obligation to provide financial support?

10. Medi-Cal Eligibility Overall Principles & Rights • Right to Apply • Reasonable Promptness • 45 days, 90 days if disability determination • Retention • Ex Parte Re-Determination - before cutting eligibility, county must see if eligible for another program • Continuous eligibility regardless of changes in income • Children for 12 months • Families losing CalWORKS/1931b due to increase in child or spousal support

11. Medi-Cal Eligibility Overall Principles & Rights • Inter-county transfers • No need to re-apply; no interruption • Bridging • Continued eligibility when moving between Medi-Cal and Healthy Families • Retroactivity • Services covered for three months prior to application • Notice and Hearing Rights • Denials, terminations, reductions, and delays

12. Medi-Cal Eligibility Cash-related Categories • CalWORKs • Supplemental Security Income (SSI) • Foster Care and Adoption Assistance • Refugee Medical Assistance/Refugee Cash Assistance (First eight months in U.S.) • No Share of Cost

13. Medi-Cal Eligibility Section 1931 • Families with net income up to 100% FPL with no share of cost • Transitional Medi-Cal • Families who lose CalWORKs or 1931 due to increased earnings • Received CalWORKs/1931 during 3 of last 6 months before losing benefits • Covers up to 12 months • First six months: Regardless of income • Second six months: Up to 185% FPL

14. Medi-Cal Eligibility Programs for Children • Federal Poverty Level/Percent Programs • Infants up to 200% FPL • Ages 1-5 (6th birthday) up to 133% FPL • Ages 6-18 (19th birthday) up to 100% FPL • No share of cost • No property/resource test • No deprivation requirement • Children Leaving Foster Care at age 18 • Must be under state control on 18th birthday • Medi-Cal until 21st birthday • No income or assets test • No share of cost • May receive all EPSDT services

15. Medi-Cal Eligibility Pregnancy-related Programs • 200% FPL Program • Presumptive Eligibility • To encourage prenatal care • Apply at prenatal care provider’s office • Must complete application for Medi-Cal • Sixty Days Postpartum Coverage • Infant deemed eligible up to one year

16. Medi-Cal Eligibility Other Medi-Cal Programs for Women and Children • Minor Consent • No Longer Disabled Children • Breast and Cervical Cancer Treatment Program (BCCTP) • Accelerated eligibility

17. Medi-Cal Eligibility Medically Needy • Income too high for cash aid • Look like CalWORKs (AFDC-MN) • Look like SSI (ABD-MN) • Must meet either: • Cash assistance deprivation requirements • SSI disability requirement • Share of cost? • Yes, if income above medically needy level • SOC = income minus MNL for that size family • No, if income below medically needy level

18. Medi-Cal Eligibility Medically Indigent • Children and pregnant women who do not meet deprivation requirements • Some children receiving foster care • Children receiving adoption assistance • People 21-65 residing in nursing homes who are there short-term and not disabled • Individuals without satisfactory immigration status in nursing homes

19. Medi-Cal Eligibility Programs for Persons who are Elderly or with Disabilities • Those receiving SSI, Aged & Disabled Medi-Cal, 250% Working Disabled • Those not receiving public assistance • Linked to case assistance program but not receiving payments; Pickles; Disabled Adult Children; Disabled widow/ers; misc.

20. Medi-Cal Eligibility Programs for Persons who are Elderly or with Disabilities • Medicare Savings Programs – pay Medicare premiums and/or deductions but do not provide Medi-Cal coverage • Qualified Medicare Beneficiary; Specified Low Income Medicare Beneficiary; Qualifying Individual; Qualified Disabled Working Individuals • Dialysis, Tuberculosis, Total Parenteral Nutrition • Not disabled; limited services; sliding scale • Nursing Facility Waivers • Income disregarded; need high level of care but allowed to live at home or in the community

21. Medi-Cal Eligibility Simplifying and Expediting the Application Process • Apply by mail, no face-to-face interview • Single Point of Entry (SPE) for Healthy Families and Medi-Cal for children and AIM • SPE screening: Children appearing eligible for free Medi-Cal get Accelerated Eligibility • Express Lane Eligibility • Food Stamp Statement of Facts • Applications for School Lunch Program • CHDP Gateway • Child Health and Disability Prevention program

22. Notice & Hearing Rights • Notices must: • Describe the intended action • Give the reasons for the action • Specify the legal support for the action • Explain hearing rights and how to get one • Explain the right to be represented • Explain the right to continued benefits, pending the appeal • Generally must be sent at least 10 days prior to the action occurring

23. Notice & Hearing Rights • For hearings: • Give reasonable notice to the beneficiary of the time & place of the hearing • Impartial hearing officer • Right to representation • Access to the file and the state’s information • Right to bring witnesses, present arguments, and cross-examine • Assistance with costs of transportation to hearing

24. Medi-Cal Services Principles & Standards • Sufficient amount, duration, and scope to reasonably achieve the service’s purpose • Reasonable promptness • Comparability—to what others receive • Statewideness—rules must be applied in all parts of the state • Freedom of choice—choose one’s own providers • Managed care waives this requirement • Medi-Cal is payer of last resort • Medicare and private insurance pay first • Medi-Cal is Payment in Full

25. Federal Mandatory Services • Hospital inpatient • Hospital outpatient • Rural health clinic • Federally qualified health clinics (FQHC) • Labs & X-rays • Nursing facilities

26. Federal Mandatory Services • EPSDT • Pregnancy-related (including post-partum) • Family planning • Physician services • Nurse-midwife services • Pediatric or family nurse practitioner • Home health services

27. Federal “Optional” Services • Podiatry • Optometry, eyeglasses • Prescription drugs • Chiropractics • Home health for non-nursing facility people • Private duty nursing • Clinical services rendered outside a clinic • TB-related drugs & care • Targeted case management • Non-emergency medical transportation services

28. Federal “Optional” Services • Dental services, dentures • Physical therapy • Other rehabilitative services • Hospice • Case management • Respiratory care • Community care • Personal care services • Primary Care Case Management • Alcohol & drug treatment • Certain care for people in mental institutions or for people with mental disabilities

29. Language Services • Title VI of the 1964 Civil Rights Act • All LEP persons must have “meaningful access’ to health care services • State Requirements • Govt. Code §11135 • Dymally-Alatorre Bilingual Services Act (Govt. Code §7290 et seq.) • Kopp Act (Health & Safety Code §1259) • Medi-Cal contract requirements

30. Budget Updates • Budget deficit - Gov’s proposal for 10% across board cuts to nearly all General Fund programs • Elimination of 10 optional services • 10% cut to already low provider rates, including cuts to disproportionate share hospitals • Reinstatement of Quarterly Status Reports for adults and children • Eliminating payment of Medicare Part B Premiums for beneficiaries who do not qualify for Medi-Cal without a share of cost • IHSS cuts

31. Where to go for more information • National Health Law Program www.healthlaw.org; (310) 204-6010 • Health Consumer Alliance www.healthconsumer.org • Health Insurance Counseling and Advocacy Program (HICAP). www.calmedicare.org; (800) 434-0222 • Benchmark Institute: • http://www.benchmarkinstitute.org/ourtraining/index.htm